Inpatient, Discharge Opioid Doses Often Mismatched After Head and Neck Surgery

More than 80% of patients undergoing head and neck surgery received mismatched opioid prescriptions at discharge, exceeding or falling short of their inpatient prescriptions, a review of 1,705 cases showed.

Almost two thirds of patients received discharge prescriptions that exceeded their inpatient prescription by more than 5 morphine milligram equivalents (MMEs). An additional 19.2% left the hospital with prescriptions that were more than 5 MMEs lower than what they received during their hospital stay.

Patients with lower prescribed opioid doses at discharge had higher refill rates, suggesting the patients might have been undertreated, reported Zhonghui Guan, MD, of the University of California San Francisco, and co-authors in JAMA Otolaryngology - Head & Neck Surgery.

"The task of postsurgical opioid management is to control opioid underprescription as well as overprescription," the authors said of their findings. "We propose to prescribe discharge opioids with inpatient consumption in mind to provide patient-centered pain management.

"A limitation of this study was the initial attempt to set 5 MME as the cutoff to determine mismatched opioid prescriptions," the team wrote. "More studies are needed to identify the proper range for discharge opioid prescription in clinical practice."

Criticism About Inherent Limitations

Emese Zsiros, MD, PhD, of Roswell Park Comprehensive Cancer Center in Buffalo, New York, who was not involved with the research, criticized the study, noting several limitations that add up to an "inherently flawed" publication.

"Firstly, the fundamental premise of the paper, which asserts that postoperative patients require a consistent opioid dosage that mirrors their intake on the final day of their hospital stay, is questionable," she told MedPage Today via email. "We must consider that as patients recover, their need for opioids tends to diminish daily. Therefore, it seems erroneous to suggest that discharge prescriptions should align with the opioid consumption in the last 24 hours prior to discharge."

Noting that the authors are anesthesiologists, not surgeons, Zsiros continued, "While their medical expertise is beyond question, they may lack practical insights regarding patients' recovery trajectories, which could have influenced the paper's conclusions. The finding that patients requested refills irrespective of being over- or underprescribed supports this argument."

At Roswell Park, clinicians review patients' opioid prescription prior to discharge, but do not aim for a direct match. The center has a two-tier system that allows two tablets every 4-6 hours as required for adequate pain control, an amount that applied to a "small fraction" of patients.

Finally, the report lacked details about the type of surgery and whether an opioid prescription was even necessary.

"The source of their data, hospital electronic health records, is well known for inaccuracies regarding previous opioid prescriptions," said Zsiros. "Furthermore, there's no mention of verifying whether patients actually filled their prescriptions, a significant oversight when they claim underprescription – which might simply indicate that the patient did not collect their prescription."

Postoperative opioid overprescription has been well documented, including after otolaryngology-head and neck surgery, Guan and colleagues noted. However, prior studies have not compared discharge opioid prescriptions with patients' daily inpatient opioid consumption. To examine the issue, the authors reviewed medical records of 1,705 patients with no opioids on their medication list or documented opioid use within 6 months of surgery.

The primary outcome was discrepancy between a patient's prescribed daily oral MME at discharge and the inpatient daily MME within 24 hours of discharge. Discrepancy was defined as a difference of at least 5 MME between the inpatient daily consumption and discharge prescription.

"Inpatient opioid consumption within 24 hours of discharge has been found to best predict postdischarge opioid use in postsurgical patients," the authors stated.

The results showed that 1,097 patients (64.3%) had discharge prescriptions that exceeded the inpatient daily dose by more than 5 MMEs (median 37.0 MME), and 327 (19.2%) had discharge doses that were more than 5 MMEs lower than the daily inpatient consumption. The remaining 281 patients (16.4%) had discharge opioid prescriptions within the 5 MME cutoff.

Subsequently, 48 patients (17.1%) with matched prescriptions requested opioid refills within 30 days of discharge. That compared with 239 (21.8%) who received higher doses at discharge (OR 1.35, 95% CI 0.96-1.92) and 99 (30.3%) who received lower doses versus inpatient daily consumption (OR 2.11, 95% CI 1.44-3.13).

Over- and underprescription occurred across all categories of otolaryngology-head and neck surgery. Use of nonopioid analgesics was not associated with opioid over- or underprescription. Cancer surgery was associated with an increased likelihood of opioid overprescription (OR 1.37, 95% CI 1.10-1.70) but not underprescription.

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